Cerebrovascular accidents, commonly known as stokes, are the fifth leading cause of death in the United States. The latest statistics from the Centers for Disease Control(CDC) put the number of stroke deaths at more than 140,000 per year. That is just the number of deaths. The number of those disabled from a stroke is much higher.
According to the CDCs stroke statistics, approximately 795,000 people suffer a stroke each year, but the good news is that strokes are one of the most preventable causes of disability. Early detection of stroke symptoms is vital, as patients who get to the hospital within the treatment window of their first symptoms are much less likely to have disabilities three months after their stroke.
It is important to know the new treatment window guidelines put out by the American Heart Association and the American Stroke Association. Now, the window for patients with clots in large vessels has been expanded to 16 to 24 hours after the first symptoms appear. Also, now patients with mild strokes who were previously unable to receive thrombolytics may benefit from them, potentially lessening their chances of long-term disability. Please note that these are special cases that highlight the importance of proper stroke care for every patient. The window for IV tPA treatment has not changed much overall and it is vital to get all suspected stroke patients to an appropriate facility quickly.
For EMS providers, the new guidelines do expand the number of people we will potentially be able to help.
Pre-hospital care providers are the lifeline in stroke situations. By the time 911 is called for someone experiencing stroke symptoms, the window of opportunity is already closing. Responding quickly and appropriately is critical to the best possible outcomes.
The ESO EMS Index, an evidenced-based database, reported 74,057 encounters where the primary impression during an EMS call was a stroke, accounting for around 1.47 percent of overall encounters. Only fifty percent (or slightly over 37,000) of those encounters were documented properly. The reasons for this quality of care issue is unclear, but merits attention system-wide.
What can be done better so that the care EMS personnel provide is able to have the greatest impact?
1. Performing full assessments every time can lead to major saves
It is our duty to correctly perform every assessment, every time. This includes every medical situation we are called to. For a suspected stroke, this is even more important because the longer a stroke goes undiagnosed, the more likely the patient will suffer death or disability. The window for treatment is quite narrow given the logistical complexities involved. A thorough assessment can be the difference between a patient being able to continue living their lives with little to no disability or a patient being seriously disabled or even dead from a stroke.
On a personal level, I have seen how much of a difference performing full assessments on patients can make. While I was the assistant chief of an EMS agency, I noticed that many patient assessments on all types of medical situations were not being fully completed. Many of these were for minor medical emergencies in which we were providing a simple transport to the hospital, but I knew this could lead down a dangerous path. What if my crews missed something major because they failed to perform a full assessment on the patient?
I implemented a policy that all of our providers were to perform full patient assessments on every call unless there were compelling reasons not to (ABCs being compromised, dangerous situations, etc). After an initial resistance from what many thought would be a time consuming and unnecessary step, we began to see positive changes. When the EMTs and medics got into a habit of performing full assessments, they became more involved in the patient in front of them. They were able to get more information from our patients such as other abnormalities the patient was experiencing that were outside of what the original call was for. They were more attentive to patient’s vital signs and how these related to the emergency. I also held classes on communication, including de-escalation training, so that our providers would be comfortable performing full assessments in all situations. The culture of our agency changed as a result and our EMTs and medics were proud of the patient reports they were able to provide hospitals due to their assessments.
If an EMS provider suspects the patient is experiencing stroke-like symptoms, then a full stroke assessment is indicated and an essential minimum requirement. Our assessments should begin with determining, to the best of our ability, when any signs, no matter how subtle, first started. We want to know when the patient’s last known “well time” was. The last time seen well is vital information for the receiving facility. Both the Los Angeles Pre-hospital Stroke Screen and the Cincinnati Pre-hospital Stroke Scale are recommended, and both are easy to use, as is the FAST score (facial droop, arm drift, speech problems test). The focus should be on rapid identification of possible stroke symptoms, looking for numbness or weakness of the face, arms, or legs, difficulty in speaking, confusion or trouble understanding simple statements, walking or balance problems, and sudden headaches.
Also important is assessing patient risk factors for stroke, such as hypertension, diabetes, atrial fibrillation, and smoking. EMS providers must obtain and continue monitoring vital signs, including blood glucose levels. To the best of their ability, a full medical history should be obtained along with a medication list.
Vital signs and neurological assessments need to be performed every 15 minutes or less as you transport rapidly to the closest appropriate facility.
Pre-hospital care is performed under very challenging and time limited conditions, so good ideas derived from experience and driven by a desire to do one’s best in service of humanity makes all the difference. Here are some ideas for how best to approach a possible stroke patient every time:
· First impressions (anything abnormal)
· Secondary information (patient or family tells you something is wrong)
· Vital signs
· Stroke assessment
· Rapid transport if indicated
Proper documentation of all medical assessments reinforces our skills and keeps us diligent. By encouraging complete documentation, we are encouraging EMTs and paramedics to perform patient care the way they have been trained to do. They will be less likely to skip steps if they document each move they make.
2. "Nailing down" time last seen normal and implications on stroke interventions.
The window for treatment, whether through the use of thrombolytics or mechanical thrombectomy, is vital to successful and safe treatment, and we want to be successful for our patients. In the pre-hospital setting, our successes with stroke care means greater impact on a patient’s quality of life.
Systematically ascertaining the time a patient was last seen well, either from a patient or a family member, saves time. The old adage applied to myocardial infarction interventions, “time is tissue,” also applies to stroke intervention. Nearly two million neurons a minute are lost in an ischemic brain event.
If the patient can’t communicate with us, then engage family or friends available at the scene as part of the assessment by asking them when they noticed things were different. Remember, even the slightest variation of pain levels or behavior, outside of what the patient or their family would consider normal, can be significant. The patient or family may tell you that their loved one started experiencing a facial droop fifteen minutes prior, but there may have been a headache that began two hours before that. That may make a difference when it comes to establishing a treatment timeframe. Many times, patients engage EMS upon waking with stroke-like symptoms. These cases are particularly challenging because frequently the time of onset communicated will be time they awoke, but the information really required is time last seen well. If they woke up with stroke-like symptoms, chances are they began experiencing them while they were sleeping. By gaining all possible information, you greatly improve the chance of saving your patient’s life.
If we can get a clear time frame of when symptoms developed, we are ahead of the ballgame. This information will be vital for our report to the receiving facility because they will start a clock and adjust it based on the information we gather. Thrombolytics, when administered quickly after stroke symptoms first develop, can greatly reduce future disability for our patients. On the flipside, thrombolytics initiated based on poor quality information may have detrimental effects.
We can be a vital link in the chain of lifesavers by nailing down the time that symptoms first develop.
3. Understanding the capabilities of area facilities and its impact on patient outcomes.
You may have many facilities in your area, but only some may specialize in stroke care. The facilities themselves may have stroke specialists or they may have partnerships that allow them to rapidly video conference with a neurology consultant to determine the correct course of action.
EMS providers must work with local facilities to know their capabilities. Often, the closest facility may seem like the best route for all patients, but for stroke patients, this may not always be the case. The American Heart Associationpoints out that “Hospitals with high stroke volumes, those with stroke units, and certified stroke centers have better patient outcomes than hospitals without this expertise, experience, and resources.”
If the patient is stable, we may see a higher long-term success rate in suspected stroke patients by taking them to facilities that can treat them with a higher levelof stroke care. We encourage EMS agencies to work with the medical control officer and local institutions to determine a “Stroke Success Strategy” that will greatly improve patient care.
The link between better coordination between EMS and area facilities is being studied by multiple groups. Duke University School of Medicine researches studied the impact of a unique partnershipbetween EMS and local hospitals. Using a phone app, EMS providers were able to alert the incoming facility to have their ED staff and stroke specialists ready when they arrived. Researchers found that this system resulted in stroke patients being more likely to receive treatment within 60 minutes of hospital arrival than patients in which this alert system wasn’t used for.
· If stroke-like symptoms are present, even minor ones, performing a full stroke assessment is indicated and can greatly improve the quality of life for our patients.
· Utilize the LA Pre-Hospital Stroke Screen or the Cincinnati Pre-Hospital Stroke Scale.
· Nail down the last time the patient was seen well.
· Understand the capabilities of all local facilities to determine the best option for your patient.
Allen Watson is a writer from the Carolina coast. He has a bachelor’s degree in political science and a master’s degree in teaching. He was an EMT-Intermediate for nearly a decade and served as assistant chief of an EMS agency for four years. You can contact him at firstname.lastname@example.org